Prehabilitation for Adults Undergoing Lower-Extremity Total Joint Arthroplasty: A Systematic Review and Meta-Analysis

Prehabilitation may improve physical readiness before total hip or knee arthroplasty. Whether frail or vulnerable patients derive benefit remains uncertain. We systematically reviewed randomized controlled trials published from 2015 to August 2026 that assessed physical or multimodal prehabilitation before total hip or knee arthroplasty. Populations were classified by validated frailty, a vulnerability proxy, or no vulnerability criterion. Random-effects models used restricted maximum likelihood estimation with Hartung-Knapp confidence intervals. Risk of bias and certainty were assessed with RoB 2 and GRADE. Thirty-eight randomized trials involving 2332 participants were included. Early patient-reported physical function showed no clear benefit (six trials; 327 participants; Hedges' g = 0.33, 95% CI -0.23 to 0.89; I² = 70.2%). Early performance-based physical function favored prehabilitation on average (10 trials; 581 participants; g = 0.48, 95% CI 0.07-0.90; I² = 76.7%), although the prediction interval crossed the null, and the restricted analysis was inconclusive. Timed Up and Go performance also favored prehabilitation (six trials; 389 participants; mean difference 1.57 s faster, 95% CI 0.86-2.28; I² = 0%). Secondary findings were limited by heterogeneity, risk of bias, and imprecision. Hospital stay was not pooled because only two compatible trials were available. Only two trials used validated frailty assessments; one contributed compatible data, precluding subgroup analysis. Prehabilitation may improve functional outcomes before and soon after arthroplasty. Evidence does not establish a greater benefit among frail patients. Future trials should use validated frailty measures and report adherence and intervention fidelity.